Reference Bradley and LofchyBradley & Lofchy (2005) should be commended for their comprehensive summary of the assessment and management of people with learning disabilities presenting in a crisis to an A&E department. As the authors rightly point out, the whole process of attending A&E can be especially frightening and anxiety-provoking for learning-disabled people. This may further exacerbate the existing crisis of agitation or aggression, possibly leading to physical violence.

In the UK, services for people with learning disabilities are most commonly provided by community learning disability teams (Reference Bouras and HoltBouras & Holt, 2004). In Birmingham, where I have been training as a specialist registrar for the past 3 years, a crisis resolution/home treatment (CRHT) team provides out-of-hours support for learning-disabled people in crisis. The team usually consists of two community learning disability nurses. They can be contacted through NHS Direct and receive out-of-hours referrals from a number of sources, including families, care homes and general practitioners. The team manages the crisis in the community (at the patient's place of residence) and has direct access to the on-call consultant learning disability psychiatrist for management advice or a joint assessment. Such management has averted a number of individuals from the A&E department or admission to an in-patient unit.

If the individual concerned responds to neither non-pharmacological nor pharmacological (excluding rapid tranquillisation, which is only done in an acute psychiatric unit) interventions, admission to an in-patient unit is considered either informally or under the Mental Health Act 1983. If an individual is in significant immediate danger of harming him- or herself or others, the police are called to take the person into custody, where the crisis team and consultant psychiatrist jointly intervene, as described above.

Although we do not yet have a CRHT team specifically for people with learning disabilities that operates during working hours, we are in the process of developing one.